ON  THE  NEUROSIS  FOLLOWING  ENTERIC  FEVER, 
KNOWN  AS  "  THE  TYPHOID  SPINE." 


By  WILLIAM  OSLER,  M.  D. 


From  the  Johns  Hopkins  Hospital  Reports,  Vol.  IV,  No.  1,  Baltimore,  Md. 


I^^MHHI 


Y._ON  THE  NEUROSIS  FOLLOWING  ENTERIC  FEVER, 
KNOWN  AS  "THE  TYPHOID  SPINE." 

By  WILLIAM   OSLER,   M.D. 

In  1889  Dr.  Gibney,  of  New  York,  described  at  the  American 
Orthopaedic  Association  a  sequel  of  enteric  fever  which  he  called 
"the  typhoid  spine,"  and  which  he  regarded  as  a  perispondylitis, 
"  meaning  an  acute  inflammation  of  the  periosteum  and  the  fibrous 
structures  which  hold  the  spinal  column  together."  He  stated  that 
his  reason  for  the  use  of  the  term  "  was  the  production  of  acute  pain 
on  the  slightest  movement,  whether  lateral  or  forward,  and  the 
absence  of  any  marked  febrile  disturbance  or  neuralgia."  He 
described  four  cases ;  in  the  first,  a  lad  of  15,  towards  the  end  of  con- 
valescence, complained  of  severe  pain  in  the  back,  particularly  in  the 
lumbar  region,  and  especially  after  any  movement.  There  was  no 
disease  of  the  bone,  no  pain  in  the  distribution  of  the  sciatic  or 
anterior  crural  nerve.  He  was  seen  in  the  autumn  of  1882,  with 
Dr.  Beverly  Robinson.  A  spinal  brace  afforded  relief,  and  in  the 
course  of  two  or  three  weeks  he  was  practically  well,  but  the  brace 
was  worn  for  more  than  a  year. 

The  second  case,  a  young  man  aged  24,  had  an  attack  of  typhoid 
fever  which  ran  a  normal  course.  After  convalescence  was  well 
established  he  complained  of  pain  in  the  back,  but  he  was  able  to  be 
up  and  about,  and  played  tennis.  After  a  fall  at  tennis  the  pain 
became  very  severe,  and  he  suffered  so  excruciatingly  that  he  could 
only  rest  in  a  recumbent  posture.  Deep  pressure  over  the  iliac 
region  on  the  left  side,  and  lateral  or  antero-posterior  motion  of  the 
spine,  caused  excessive  pain.  He  had  some  fever.  The  symptoms 
persisted  from  the  latter  part  of  November  until  the  beginning  of 
January,  but  it  was  not  until  March  that  he  was  able  to  get  about. 

The  third  case,  a  lad  of  18,  had  typhoid  fever  in  November,  was 
convalescent  by  December  27th,  and  went  to  New  York.  On  January 
10th  he  fell  while  skating  and  struck  his  left  hip.  A  week  after  this 
he  had  pain  in  the  region  of  the  lumbar  spine.  The  stiffness  became 
more  marked  and  the  pains  increased  in  severity.     On  the  10th  of 


74  William   Osier.  [74 

February  ho  went  to  bed  and  was  seen  by  a  surgeon  in  Albany,  who 
regarded  the  case  as  one  of  psoas  abscess.  There  was  no  fever,  no 
evidence  of  disease  of  the  spine,  but  the  patient  could  not  move  with- 
out exquisite  pain.     He  did  not  recover  until  May. 

The  fourth  case  seems  to  me  to  belong  to  an  entirely  different 
category,  as  it  was  an  instance  in  which,  during  typhoid  fever,  the 
boy  had  kept  both  limbs  flexed  on  the  abdomen,  and  during  conva- 
lescence was  unable  to  straighten  them,  an  event  met  with  in  many 
protracted  illnesses  in  which  the  patient  lies  curled  up  in  bed  with 
the  legs  flexed. 

In  1890,  in  a  discussion  at  the  Association  of  American  Physicians 
following  the  reading  of  a  paper  on  some  points  in  the  natural  history 
of  enteric  or  typhoid  fever,  by  Dr.  James  E  Reeves,*  Dr.  Loomis,  Sr., 
referred  to  Dr.  Gibney's  observations,  and  to  one  of  the  cases  he  had 
asked  Dr.  Gibney  to  see.  Dr.  Loomis  knew  of  no  reference  in  litera- 
ture to  a  similar  condition.  Dr.  Jacobi,  at  the  same  meeting,  besides 
protesting  against  the  introduction  of  a  new  name,  such  as  "  typhoid 
spine,"  suggested  that,  in  the  absence  of  temperature,  it  might  be 
one  of  two  things,  either  a  neurosis  or  a  spondylitis,  remarking  that 
mild  forms  of  spondylitis  are  not  so  uncommon  as  they  are  believed 
to  be. 

In  the  American  Text-book  of  Medicine  (page  90)  Dr.  Pepper 
remarks  in  his  article  on  typhoid  fever  that  he  has  observed  in  a 
series  of  cases  "  obstinate  peri-osteitis  of  the  sternum  or  of  the  crests 
of  the  ilia,  or  in  two  instances,  judging  from  the  location  of  the  pain 
and  from  the  effect  of  movement  of  the  trunk,  of  the  front  of  the 
spinal  column."     Eskridge  also  described  a  case  last  year. 

I  have  not  been  able  to  find  any  other  references  in  text-books  or 
monographs  on  typhoid  fever,  either  in  English,  French  or  German. 
My  attention  had  not  been  called  to  the  condition  until  recently, 
unless  perhaps  a  case  which  I  saw  several  years  ago  with  Dr.  Gra- 
sett,  of  Toronto,  was  an  illustration ;  a  young  officer,  invalided  from 
India  after  a  prolonged  fever,  had  for  many  months,  on  the  slightest 
movement,  attacks  of  the  most  severe  pain  in  the  back,  which 
incapacitated  him  completely,  though  when  seen  by  me  he  looked 
strong  and  robust  and  had  a  good  appetite.  He  subsequently  got 
quite  well. 

*  Transactions  of  the  Association  of  American  Physicians,  vol.  v.,  1890. 


75]  The   Typhoid  Spine.  75 

The  two  following  cases  are,  I  think,  illustrative  of  the  condition 
which  Dr.  Gibney  has  described  : 

Case  I. — O.  T.,  aged  25  (Hos.  No.  8201),  admitted  complaining 
of  pains  in  the  back,  hips  and  stomach.  The  family  history  is  good. 
His  father  and  mother  are  living  and  well.  One  brother  died  of 
typhoid  fever. 

Patient  was  strong  and  well  until  July,  1892,  when  he  had  a  very 
severe  attack  of  typhoid  fever  with  relapse.  He  was  in  bed  for 
nearly  three  months;  very  slow  convalescence.  He  remained  well 
for  three  weeks,  when  the  present  illness  began  with  pains  in  the 
back  and  hips,  usually  of  a  shooting  character,  and  paroxysms  of 
pain  in  the  abdomen,  of  which  he  would  sometimes  have  several  in 
the  day.  He  had  to  take  again  to  his  bed  and  was  there  for  seven 
weeks,  having  much  pain  in  the  lower  part  of  the  back  and  down 
the  front  of  the  legs.  He  never  apparently,  from  his  account,  had 
any  paralysis.  About  June  of  this  year  he  was  well  enough 
to  go  out  and  do  light  work  about  the  farm.  In  the  latter  part 
of  June  he  had  another  attack  of  severe  pain  in  the  back  and 
abdomen.  He  had  not  to  go  to  bed.  There  was  much  aching  pain 
and  shooting  in  the  right  leg  from  the  hip  down  to  the  knee.  In 
the  latter  part  of  July  and  in  August  he  had  severe  attacks  of 
diarrhoea.  Since  August  he  has  been  up  and  about,  but  not  work- 
ing, and  has  been  able  to  go  out  shooting.  At  present  he  has  slight 
pains  at  times  in  the  back  and  in  the  legs,  and  yesterday  there  was  an 
aching  pain  from  the  left  knee  to  the  ankle.  The  appetite  is  good. 
He  never  vomits,  though  he  often  has  eructations.  Bowels  are 
costive.     He  sometimes  has  dyspnoea  on  exertion. 

Present  Condition. — Healthy  looking,  well-nourished  man,  with 
fairly  well-developed  musculature.  He  gives  one  the  impression  of 
a  neurasthenic  patient.  Lips  and  mucous  membranes  of  good  color ; 
tongue  clean  and  moist;  pupils  equal;  pulse  70°  to  80°;  no  increase 
in  tension.  Practically  the  examination  of  the  thoracic  and  abdom- 
inal organs  was  negative.  The  abdomen  was  soft  and  nowhere 
tender.  The  chief  complaint  is  of  weakness  in  the  back,  and  it 
hurts  him  to  turn  in  bed.  He  describes  the  pain  which  he  had  last 
year  as  beginning  in  the  small  of  the  back,  passing  around  the  hip 
bones  and  then  up  the  back.  Judging  from  the  scarring,  the  chief 
trouble  was  thought  to  be  in  the  lower  part  of  the  spine.  There  is 
still  a  little  tenderness  on  pressure  just  above  the  left  sacro-iliac 


76  William    Osier.  [76 

synchondrosis.  There  is  no  tenderness  over  the  sacrum  itself,  or 
along  the  iliac  crests.  Patient  gets  out  of  bed  readily  and  stands 
well ;  walks  with  a  natural  gait;  does  not  sway  with  the  eyes  shut. 
After  prolonged  standing  or  walking  he  complains  of  great  increase 
of  pains  in  the  back.  The  knee-jerks  are  present,  a  little  exagger- 
ated ;  there  is  no  ankle  clonus.  The  most  careful  examination  of 
the  spine  fails  to  reveal  any  signs  of  organic  disease.  The  urine  is 
normal. 

The  patient  remained  in  hospital  for  a  little  more  than  a  week  j 
took  large  doses  of  nux  vomica,  and  was  encouraged  to  believe  that 
he  had  no  serious  organic  disease.  Subsequent  examinations  gave 
no  additional  information,  but  the  patient  evidently  was  highly 
neurasthenic. 

Case  II. — A.  A.,  aged  21,  architect's  assistant,  seen  with  Dr.  King, 
May  10th,  1893.  Patient  has  always  been  a  healthy  man  and  has 
never  had  any  very  serious  illness.  He  is  not  of  a  robust  constitu- 
tion, and  though  bright,  not  of  a  very  strong  mental  fibre.  There 
are  no  special  nervous  troubles  in  the  family. 

In  November  and  December  last,  patient  had  typhoid  fever,  an 
attack  of  moderate  severity.  On  New  Year's  day  he  sat  up  for  the 
first  time,  and  convalescence  was  gradually  established.  There  were 
no  sequelae,  no  complications,  and  early  in  February  he  went  to  his 
work.  He  gained  in  weight  and  looked  very  well.  He  remained 
at  work  about  three  weeks,  complaining  only  at  times  of  pain  in  the 
back  and  of  being  very  tired  after  sitting  for  a  long  time.  One  day 
he  was  very  much  jarred  in  the  back  during  a  sudden  jerking  of  a 
cable  car  in  which  he  was  riding.  Early  in  March,  after  complain- 
ing very  much  of  his  back  and  of  the  pain  on  moving,  and  of  tired 
feelings,  he  took  to  his  bed,  where  he  has  remained  ever  since. 
Dr.  King  tells  me  that  the  chief  symptom  has  been  pain  on  move- 
ment. His  general  health  has  been  excellent.  The  appetite  has 
been  good,  he  has  gained  in  weight,  and  he  has  slept  well.  He  has 
been  nervous  and  at  times  almost  hysterical.  When  quiet  and  at 
rest  and  not  attempting  any  movement  he  does  not  complain  of  pain, 
but  on  turning  or  on  attempting  to  get  out  of  bed,  or  even  the 
thought  of  the  attempt  to  move  the  legs,  is  enough  to  cause  him  to 
cry  out.  The  pains  have  been  in  the  lower  part  of  the  back,  extend- 
ing  sometimes   up  the  spine  and  down  the  back  and  sides,  more 


77]  The  Typhoid  Spine.  77 

rarely  the  front  of  the  leg  as  far  as  the  knee.  He  has  had  no  fiver, 
no  chills,  but  has  sweated  a  good  deal.  He  h:ts  had  no  swelling  of 
the  joints. 

Present  Condition. — Patient  is  a  well-grown  young  man,  well  nour- 
ished, musculature  of  moderate  development.  The  palms  of  the 
hands  are  moist  and  sweating;  he  was  somewhat  excited,  and  at 
our  entrance  flushed  over  the  cheeks  and  neck  and  upper  part  of  the 
chest.  Face  does  not  indicate  any  special  strength  of  character, 
rather  the  reverse.  Pupils  of  medium  size,  equal,  active;  tongue 
clean.  Patient  in  the  dorsal  decubitus,  his  usual  attitude.  On 
pulling  down  the  bedclothes  he  implored  us  not  to  touch  him,  as  he 
was  sure  it  would  hurt  him  very  much.  The  abdomen  was  full, 
natural  looking.  On  palpation  he  complained  of  a  good  deal  of 
pain  in  the  left  iliac  region,  but  on  withdrawing  his  attention  and 
pressing  forcibly  with  the  left  hand  in  the  region  of  the  heart  and 
asking  whether  he  had  pain  here,  the  right  hand  at  the  same  time 
could  be  pressed  deeply  into  the  iliac  fossa  without  causing  any  dis- 
turbance. The  deepest  pressure  in  the  lumbar  and  iliac  regions 
failed  to  reveal  any  glandular  enlargements  or  thickening.  The 
inguinal  glands  not  enlarged;  no  special  sensitiveness  along  the  ante- 
rior crural  nerves.  On  asking  him  to  lift  the  leg  he  said  it 
was  impossible,  as  it  hurt  him  so  much,  but  in  a  few  moments, 
placing  the  hand  beneath  it,  he  lifted  it  apparently  without  pain. 
When  lifted  in  a  semi-flexed  position  he  said  it  was  impossible  for 
him  to  straighten  it,  but  in  a  few  moments  it  could  be  readily 
extended  and  he  straightened  it  easily  on  the  bed.  There  was 
no  special  wasting  of  the  legs.  He  could  move  all  the  muscles 
freely  and  was  able  to  get  up  and  stand  on  his  legs  if  he  took  time. 
The  sensation  was  perfect ;  the  knee-jerks  present,  perhaps  a  little 
exaggerated  ;  no  ankle  clonus.  The  feet  and  ankles  were  perspiring 
freely.  No  swelling  of  the  articulations,  and  no  pain  on  pressure  of 
the  muscles  or  in  the  popliteal  spaces.  On  asking  him  to  turn  over 
on  his  left  side  he  demurred  very  much,  but  gradually,  and  apparently 
with  a  great  deal  of  difficulty,  he  got  himself  over.  The  legs  could 
then  be  moved  easily  and  freely ;  no  pain  about  the  hip  joint,  and 
the  legs  could  be  flexed  and  extended  readily.  The  spine  was 
straight;  the  lower  dorsal  vertebras  a  little  prominent.  Xo  tender- 
ness at  any  point  along  the  spinal  column.  On  both  sides  in  the 
lower  lumbar  and  sacral  regions  he  was  sensitive  at  a  distance  of  an 


78  William   Oder.  [78 

inch  and  a  half  or  two  inches  from  the  middle  line,  and  particularly 
towards  the  right  sacro-iliac  synchondrosis,  and  along  the  posterior 
third  of  the  crest  of  the  ileum.  He  stated  that  this  was  really  the 
point  of  greatest  pain.  Any  attempt  at  twisting  the  spinal  column 
was  very  sensitive  and  we  could  not  induce  him  to  sit  up.  In  the 
attempts  to  make  this  movement  he  seemed  to  suffer  a  great  deal 
of  pain  and  began  to  cry. 

There  were  no  sensory  changes,  no  hemianesthesia,  no  hemi- 
anopsia. The  patient  said  that  his  chief  trouble  was  more  the  dread 
of  moving,  lest  it  should  cause  pain,  than  any  pain  itself.  Four 
days  ago  he  sat  up  for  a  couple  of  hours,  got  out  of  bed  himself  and 
sat  on  the  chair,  but  felt  very  tired,  and  the  back  was  painful.  Prac- 
tically the  examination  in  this  case  revealed  neither  Potts'  disease 
nor  neuritis. 

He  was  ordered  massage  and  electricity,  and  the  Paquelin  cautery 
to  the  back,  given  strychnia  internally,  and  urged  to  sit  up  a  certain 
definite  time  each  day. 

June  10th.  A  few  days  after  I  saw  him  he  was  able  to  sit  up  and 
did  very  well.  Went  out  on  the  30th  of  May  and  has  been  doing 
remarkably  well  ever  since.  Called  to-day,  looks  in  very  good  con- 
dition. No  pain  in  the  back ;  feels  a  little  stiff;  knee  jerks  are 
normal;  condition  good. 

Cases  II  and  III  in  Dr.  Gibney\s  paper  are  very  much  like  the 
one  here  mentioned,  particularly  in  the  fact  that  the  symptoms  devel- 
oped after  convalescence,  and  in  both  instances  there  was  a  slight 
trauma ;  in  one  a  fall  while  playing  tennis,  and  in  another  a  slight 
fall  on  the  left  hip  while  skating.  In  the  case  reported  here  the 
patient  also  lays  a  great  deal  of  stress  on  the  jar  which  he  received 
by  the  sudden  jerking  of  the  cable  car.  In  both  of  these  cases  the 
prominent  symptom  was  pain  on  movement,  and  there  was  an  absence 
of  all  signs  of  organic  disease. 

An  explanation  of  the  symptoms  in  these  cases  is  by  no  means  easy. 
As  already  mentioned,  Dr.  Gibney  regarded  the  lesion  as  a  peri- 
spondylitis, an  acute  inflammation  of  the  periosteum  and  fibrous 
structures  holding  the  spinal  column  together ;  and  with  this  view, 
judging  from  the  quotation  given,  Dr.  Pepper  seems  to  agree. 

Joint  and  periosteal  troubles  are  by  no  means  rare  sequences  of 
typhoid  fever,  but  the  symptoms  do  not  usually  develop  (as  in  three 


79]  The  Typhoid  Spirit.  79 

or  four  of  the  cases  here  described)  at  so  long  a  time  after  convales- 
cence has  been  well  established.  The  periostitis,  seen  of'tene.-t  aboul 
the  sternum  and  the  ribs,  proceeds  as  a  rule,  but  not  necessarily, 
to  suppuration.  I  have  in  several  instances  seen  a  periosteal  swelling 
disappear  without  suppuration.  We  do  not  have,  so  far  afl  I  know, 
protracted  periosteal  thickening,  lasting  for  weeks  or  months,  without 
suppuration  :  and  it  is  difficult  to  conceive  of  the  attacks  of  pain,  Buch 
as  are  described  in  the  second  and  third  cases  of  Dr.  Gibney's,  and 
in  the  second  case  which  I  here  report,  lasting  for  months,  du< 
simple  perispondylitis  which  in  none  of  the  cases  passed  on  to  sup- 
puration. In  both  of  my  cases  the  general  impression  given  by  the 
patients  was  that  they  were  neurasthenic  ;  and  while  of  course  it  would 
be  very  illogical  to  assume  that  all  of  the  instances  are  due  to  the 
same  cause,  yet  I  cannot  help  feeling  that  many  of  them  are  examples 
simply  of  the  painful  neurosis  formerly  known  as  "  spinal  irritation/' 
and  analogous  to  the  painful  condition  met  with  in  the  "  hysterical 
spine "  and  the  "railway  spine,"  in  both  of  which  the  patient  may 
have  pains  on  the  slightest  movement  of  the  back  or  of  the  legs.  In 
the  second  case  reported,  the  whole  behavior  during  the  examination 
was  that  of  a  hysterical  patient;  thus,  he  could  not  think  of  lifting 
a  leg — even  the  idea  was  enough  to  give  him  agonizing  pain,  and 
yet  in  a  few  minutes  he  lifted  it  himself  and  got  out  of  bed.  So  also 
the  slightest  pressure  in  the  lumbar  or  iliac  regions  would  cause  him 
to  scream  out,  but  while  his  attention  was  directed  elsewhere,  pres- 
sure could  be  made  with  the  greatest  facility.  The  rapid  recovery 
in  a  few  days,  with  disappearance  of  all  the  symptoms,  is  quite 
inconsistent  with  a  chronic  perispondylitis. 

I  have  recently  seen  a  case  presenting  somewhat  different  features, 
but  which  I  think  may  also  be  reasonably  classed  as  a  post-typhoid 
neurosis. 

Case  III. — A.  B.,  aged  about  30,  New  York  City,  consulted  me 
Nov.  2nd,  1893,  stating  that  he  had  had  trouble  with  his  spinal  cord. 
Family  history  was  good ;  parents  living ;  one  sister,  however,  is 
insane. 

He  was  nervous  as  a  boy;  used  to  tremble  very  much  when 
excited,  and  had  "nervous  fits."  He  had  gonorrhoea  three  or  four 
times;  never  had  lues;  acknowledges  excesses  in  ventre.  Takes 
alcohol,  but  is  not  a  hard  drinker. 

September  23rd,  1891,  he  had  an  attack  of  typhoid  fever  of  unusual 


80  William    Oder.  [80 

severity,  with  prolonged  delirium,  extensive  bed-sores,  and  very  great 
prostration.  Convalescence  was  not  established  until  January  10th, 
1892.  During  and  after  convalescence  he  was  very  nervous,  and 
had  uneasy  pains  in  the  legs,  his  feet  were  tender,  and  he  tired  very 
easily.  He  had  no  pain  in  the  back,  no  soreness,  but  the  tenderness 
in  the  feet  and  nervous  feelings  persisted  for  six  or  eight  months  after 
convalescence,  and  he  does  not  think  that  they  have  ever  entirely 
disappeared.  He  attended,  however,  to  his  business,  gained  in 
weight,  and  felt  pretty  well,  though  never  entirely  free  from  uneasv 
sensations  in  the  feet  and  legs.  In  the  spring  of  this  year  these 
symptoms  increased,  particularly  after  some  sprees.  He  had  neur- 
algic pains  in  the  legs,  and  he  felt  weak  and  unstrung,  and  evidently 
got  into  a  very  nervous  condition.  He  had  a  dread  of  walking,  and 
could  scarcely  force  himself  to  go  as  far  as  the  corner  of  the  street. 
He  slept  badly  and  got  into  a  state  of  extreme  neurasthenia.  There 
were  twitchings  of  the  muscles,  and  the  feet  and  hands  felt  numb,  and 
he  complained  that  when  his  shoes  and  stockings  were  off  there  was 
a  smooth  feeling  as  if  something  was  between  the  feet  and  the  floor. 
At  this  time  a  doctor  in  Newr  York  suggested  there  was  oncoming 
spinal  trouble,  and  stated  that  in  testing  the  sensation  over  the 
spine  with  hot  and  cold  water  he  could  not  distinguish  between 
them.  He  ordered  him  electricity  and  massage  and  general  tonics  ; 
for  the  past  seven  or  eight  weeks  he  has  not  been  at  work  and  has 
improved  a  good  deal. 

Present  Condition. — Tall,  able-bodied  man ;  looks  a  little  pale ; 
gait  is  normal;  not  spastic;  station  good;  no  Romberg  symptom; 
no  atrophy  of  the  muscles ;  legs  scarcely  in  proportion,  however,  to 
the  rest  of  the  muscular  development.  The  spine  is  straight,  nowhere 
painful  on  pressure,  no  special  prominence  of  any  vertebra.  Sensa- 
tion is  everywhere  good,  no  retardation,  distinguishes  easily  between 
heat  and  cold.  He  thinks  that  about  the  feet  and  ankles  the  sensation 
is  a  little  blurred  and  unnatural.  He  feels,  however,  a  sharp  point, 
and  distinguishes  readily  different  objects,  and  the  thermic  and  pain- 
ful sensations  are  unaffected.  He  has  no  abnormal  sensations  about 
the  back  and  abdomen,  and  has  not  any  sense  of  constriction  or 
girdle  pain.  There  is  no  vaso-motor  disturbance.  He  sweats,  how- 
ever, easily  and  the  hands  are  clammy,  and  he  has  had  at  times,  he 
states,  marked  blueness  and  congestion  of  the  feet,  and  they  are  often 
cold  in  the  morning. 


81]  The  Typhoid  Spin,:  81 

The  reflexes  are  increased;  knee-jerks  active,  particularly  on  the 
left  side,  and  a  slight  ankle  clonus  can  be  obtained.  The  skin  reflexes 
are  normal.     There  is  no  disturbance  of  the  special  senses.     The 

pupils  are  a  little  large,  equal,  react  to  light.     The  optic  disl 
normal;  there  is  no  restriction  of  the  visual  fields. 

The  examination  of  the  thoracic  and  abdominal  organs  is  negative. 

Here,  after  a  protracted  and  severe  attack  of  typhoid  fever  with 
delirium,  severe  nervous  symptoms  and  tardy  convalescence,  th<- 
patient  had  disturbed  sensations  in  the  feet  and  legs.  The  symp- 
toms diminished  somewhat  within  five  or  six  months,  never  entirely 
disappeared,  and  recurred  with  intensity  during  a  period  character- 
ized by  pronounced  neurotic  manifestations.  Unlike  the  cases  before 
described,  there  were  no  pains  in  the  back  or  abdomen,  only  a  sen- 
sation of  weakness.  The  symptoms  suggest:  (1)  central  (spinal) 
lesion ;  (2)  neuritis ;  or  (3)  a  neurosis.  From  his  statements  it  was 
evident  that  the  doctor  in  attendance  feared  a  central  affection,  but 
it  would  seem  that  the  patient's  condition  now,  two  years  from  the 
date  of  the  fever,  would  speak  very  strongly  against  any  such  view ; 
nor  does  the  case  conform  in  its  clinical  history  to  a  neuritis.  The 
man  insists  that  the  same  feelings  which  he  has  now  in  the  feet  were 
present  during  the  convalescence  from  the  attack  and  some  months 
subsequently.  There  did  not  appear  to  have  been  any  very  special 
muscular  weakness  such  as  sometimes  develops  after  a  protracted 
attack  of  typhoid  fever  without  any  evidence  of  peripheral  neuritis. 
In  the  paper  by  Dr.  George  Ross  on  Paralysis  after  Typhoid  Fever* 
he  refers  to  these  cases  in  the  following  words :  "It  is  not  unusual 
after  typhoid  fever  of  considerable  severity  to  find  a  definitely 
enfeebled  condition  of  the  lower  extremities  persisting  for  some  time, 
and  sometimes  a  person  never  entirely  recovers  his  capacity  for 
walking  long  distances.  Such  paretic  cases  have  never  been  specially 
studied,  but  it  is  probable  they  would,  if  any  should  fall  under  the 
head  of  defective  innervation  from  prolonged  exhaustion  of  the 
nervous  centres."  In  the  case  under  discussion,  the  history  and  the 
general  appearance  of  the  patient  suggest  rather  a  neurosis  following 
typhoid  fever.  The  paresthesias  such  as  he  described  are  not 
uncommon  symptoms  of  neurasthenia,  in  which  also  exaggerated 
reflexes  are  not  at  all  infrequent. 

*  Transactions  of  the  Association  of  American  Physicians,  Vol.  Ill,  18S8. 


82  William    Osier.  [82 

It  is  not  unlikely  that  under  the  designation  of  "  typhoid  spine" 
Dr.  Gibneyhas  described  several  distinct  affections,  and  I  would  not 
be  understood  as  holding  that  there  may  not  be  a  perispondylitis. 
Nor  indeed  are  all  the  painful  backs  in  typhoid  fever  neurotic;  thus, 
a  patient  recently  under  my  care  (Hos.  No.  8049)  was  admitted  in  an 
attack  of  moderate  severity  about  the  end  of  the  third  week,  the  tem- 
perature falling  to  normal  by  the  26th  day;  then  after  a  period  of 
apyrexia  of  seven  or  eight  days  he  had  a  well-marked  relapse  of  about 
two  weeks'  duration.  During  convalescence  he  began  to  complain 
of  severe  pain  in  the  back  of  the  neck,  and  at  the  attachment  of  the 
muscles  of  the  occipital  bone.  There  was  no  actual  tenderness  in  the 
vertebras,  and  movements  to  and  fro  and  laterally  were  not  associated 
with  any  very  great  pain.  An  application  of  the  Paquelin  cautery 
relieved  it  for  a  few  days,  and  then  it  recurred.  The  examination 
from  the  pharynx  was  negative.  The  condition  persisted  for  at  least 
two  weeks,  and  while  at  first  confined  to  the  neck,  subsequently  he 
had  soreness  and  stiffness  of  the  back;  he  walked  stiffly  and  held 
himself  very  erect.  He  says  that  it  is  better  when  moving  about 
than  when  lying  down.  No  special  tenderness  in  the  spine,  and  no 
sharp  pain;  no  increase  in  the  reflexes;  no  indication  of  neuritis. 
He  gradually  improved,  and  when  discharged  he  was  very  much 
better,  having  gained  11 J  pounds  in  weight. 


■*■  "«>.  cam*  ua. 


